At the Centre of a Scandal

Rarely does one find oneself actually having worked in what is shaping up to be a major political scandal.

Thoracic surgery at the C of E was a poor cousin to cardiac. This was unfortunate for them as they shared beds and operating time and guess who won out there.

About 5 years into my tenure at the C of E a new thoracic surgeon was recruited. Now at the C of E at that time there was only room for one thoracic surgeon which as you can see could potentially cause some problems.

The fellow they recruited was a local boy who trained at another centre and had done some training over in Britain. He was technically not a bad surgeon, he was a little whiny, he liked to operate at night etc. Despite some interpersonal problem I had with him early on, we actually got along, and I actually enjoyed working with him. After a few years, he started to complain about things like not being able to recruit other thoracic surgeons due to lack of OR time (which meant he had to be on call every night), and his beds being filled by cardiac surgery patients meaning that he often had cases canceled due to no beds. He also couldn't get beds in the cardiothoracic ICU, the hospital wouldn't open a step down unit which was all most of his patients needed. He also complained about being on call every night because the hospital couldn't or wouldn't recruit another thoracic surgeon. Briefly a city wide call schedule was instituted but the other surgeons in the city soon tired of working at the C of E at night.

Suddenly he was gone. The story which I only heard today was that one day he arrived to find the locks on his office changed and the chief of surgery and two security guards waiting. He was escorted from the building.

In his place was a wise man from the East, a thoracic surgeon recruited from Toronto. He seemed to be a nice guy a first, he was fast, and didn't always want the lung down. Soon it became apparent there were problems with him. His judgment seemed a little questionable; we started seeing his patients on ventilators in recovery; he insisted on operating on patients we wanted to cancel, he left residents in the room and couldn't be located when the shzt hit the fan. At the same time suddenly we got a step down unit, there never seemed to be cancellations of thoracic cases and two more thoracic surgeons were recruited.

Rumours then started flying about how this wise man had been recruited to evaluate the whiny one's practice and being told, " Oh by the way how would you like to work here?"

Things rapidly went south, the two other thoracic surgeons moved to other hospitals mainly because they didn't like working with the wise man from the east. I left the C of E. I think that the prospect of working with the wise man was a major factor in my leaving. About a year after I left, I got a memo stating that the wise man was taking a leave of absence. He has never returned from this.

Why am I digging up more dirt on the C of E.

This fellow a physician member of our legislature has been making accusations of cover ups of cancer deaths on the wait lists and pay-offs to physicians. My first impulse was that even our health authority and government aren't that malicious. Then I thought about the whiny one. And today this appears on the front page of my local paper .

The whiny one of course sued and according to scuttlebutt around the OR today got between 8 and 12 MILLION dollars in an out of court settlement. No wonder he is smiling.

And here I was at the centre of it all. Sad to think of how many nurses 12 million could have paid for.

Unmasked Sort Of

I started this blog in a moment of boredom on New Year's eve 2006. I was on call, my family were at the dacha, there were no cases on and the case room was quiet. I sat at home. There is never anything good on TV on New Years eve so I started fooling around on my computer and that was when I started this blog.

I never thought it would amount to much but I kept on writing. Gradually people started commenting, I saw other blogs were linking to mine and I kept on writing. Some of posts I have written, I am really proud of; a lot are petty or stupid.

Throughout that I never told me wife. Until yesterday. I had always intended to tell her but as the months went on and I still hadn't told her, it got harder. While I write anonymously, I have given out so many hints that anybody who reads the blog can figure out who is writing it pretty easily if they know me. I was worried she might actually stumble on it that way. Anyway I told her on the way to dinner yesterday and after dinner she read most of my posts some of which I explained to her. She reacted pretty well on the whole. I never had told her about the problems I had during my internship, nor about my sexual harassment complaint. We of course went through my lawsuit and my bad marriage with the C of E together.

This blog was sort of like a perverse diary where you hide it from your family but the entire Web is able to read it. Not anymore.

By the way as she is probably going to read this: She is an amazing woman who has been a constant source of support through all the shit I have been through and all the shit I have put my family through.

Ending My Silence on the King's Speech

There are a lot of good movies out lately and so when my wife announced on date night that she wanted to see the King's Speech I was a little hesitant but I went and thoroughly enjoyed it.

I stutter. Many fellow stutterers have writen about this, much more eloquently than I can.

This, as I remember started in Grade I. I probably started before that but with the reading out loud, you have to do in Grade I it became apparent. My Grade I teacher alertly picked this up and I was started on speech therapy that year which lasted until Grade 5. Once a week an old English lady, Miss Crickmay would appear at the door of our classroom and another student and I would go for our weekly speech therapy sessions. This mostly consisted of reading from our readers and being told not to talk loudly and read slowly. The sessions stopped after Grade 5. I believe I had broken her spirit.

I went thru a lot of teasing throughout school. I remember in Grade 1 we would have the morning and afternoon role calls. As the teacher called out our names we would have to say, "Good morning Mrs. Murphy" or "Good afternoon, Mrs. Murphy". That instead of just saying "here" or "present". I could easily say "good afternoon"; "good morning" was a daily ordeal. In Grade 2 I was actually placed in the dummy reading group until the teacher realized that I could read better than anybody in the class. I went to the same school from Grades 1-7; as I got along, the other students knew that I stuttered, the teasing stopped; some other students came to my defense if somebody imitated me or laughed.

Junior high was another matter. Only half our school when to that Junior High and there were three other feeder schools. A whole new group of students to whom I was going to have get to know. My solution was to clam up. I only spoke when spoken to and stuck with my small group of friends. I believe that as a result of this I missed a lot of socialization during adolescence. I still have a hard time making conversation, people find me aloof. I really wanted to learn French in junior high so I took an enhanced course. Part of the reason may have been that I felt I could be more fluent in another language. As I found out I stutter in French although not as badly as in English probably because I have to speak slower and think more in French. Nonetheless, French class became an ordeal.

When I was in high school there was a televised quiz show for high schools called Reach for the Top. I am especially good at trivia, so much to everybody's, but not my, surprise I made the team in Grade 11. I have only recently thought of how stressful this must have been for my parents. Their stuttering son on TV at 7:30 in the evening, broadcast province-wide. Fortunately for some reason I usually don't stutter under pressure and the one word and short phrase answers required for these shows never bothered me.

Notwithstanding Miss Crickmay's efforts I did come to a truce with my stutter but it is an uneasy and frequently violated truce. Soft S's and C's are difficult as are H's and W's. For example scissors is a word I have a hard time saying (I actually bought my own as an intern so I wouldn't have to ask the nurses). Worse are the times when I just self destruct, the words stop flowing, I grimace, my tongue protrudes from my mouth. These come without warning; I can be in the middle of a conversation and without warning the attack will come. I do a lot of speaking now, I have learned that after about half an hour this may happen. I have learned to have a glass of water handy more to use as a prop while I wait to reset. I like King George and Winston Churchill try to avoid words I know I cannot say. This is frequently awkward, in medicine with its most precise terminology it is often impossible to avoid certain words. Like King George, I don't stutter when angry and I can swear. I like to sing in private. I went thru my fellowship oral exam completely fluently, I have no idea how or why.

Alcohol of course makes it worse. I hold my liquor rather well except when it comes to speaking when I frequently appear way drunker than I am. Coffee is another villain. I try to avoid coffee when I have to give a talk. I stutter more when I am tired. There is an obsessive component to it, certain situations make me stutter more.

Public speaking is another source of stress in my life. I dreaded the presentations we had to give in medical school; presenting a case in a small group was never a problem (except that I tend to be very to the point which a lot of people don't like). When I was a resident we had to present a lot more. I suddenly found that I enjoyed it. I loved researching a topic and breaking it down to a way that an audience could understand. I was also able to structure it in a way that I could actually present it effectively. I now do a lot of talks for the medical school and mostly for Big Pharma. For the most part I am able to get through them. Early on I remember giving a talk for the dental class on head and neck pain and all of a sudden self destructing, limping to a finish. I was never invited back. Nonetheless I have spoken at two national meetings as an invited speaker, something I am still very proud of.

I now attend a lot of meetings. Depending on how I am feeling, I may or may not participate in the discussion. Sometimes this has been to my detriment, I often actually have something useful to say. I frequently now send letters or emails after the meeting; I just thought of this I say, although I probably thought about it during the meeting. I often think about how if I had spoken up at staff meetings when I was at the Centre of Excellence, that I might have changed the way things went. Nah.

A few years ago I resolved to kill the beast once and for all and attended weekly sessions at ISTAR. I found them helpful but at the end I got the impression that I was as good as I was ever going to get and that there were people worse than me. Still I highly recommend them to anybody. By the way they are always looking for donations.

Interractions with patients are interesting. People will think I chose anaesthesiology as a specialty where I would not have to talk to people. Everybody knows, don't they, anaesthesiologists never talk to patients. As such my choice of chronic pain is questionable. I was never a good family doctor; my stutter might have contributed to it. It may have made me appear less sure of what I was telling patients. It made me more direct and to the point which some people like, most don't. In certain practices I worked in, the doctor's practice was to call the patient in from the waiting room. Certain names of course I have trouble saying. At work, sometime asking for stuff is difficult; I am known as someone who is fairly self sufficient, I would rather just get something myself. When this happened my ever supportive chairman suggested that I had not more thoroughly interogated the surgeon or asked for help because of my stutter. I don't think so but what if?

I realize this is a handicap but that I am more fortunate than people who are blind, deaf or have a mobility problem, many of who have overcome their problems to go on to great things. On the other hand it is handicap not always accepted by society. I remember being always being told to speak slowly and other hints. I was told that I could stop stuttering as if I really wanted to just keep on doing it. As a teenager I remember thanking my father for something and being told, "you can thank me by stopping stuttering."

Stuttering of course runs in the family. The gene has apparently even been localized. My father stutters although he mostly overcame it, my younger brother (but not my other brothers) stutters. I have a cousin I have never met who stutters. Painfully for me, my son also stutters although after a year long ordeal of speech therapy he controls it much better than do I.

I thank the writers and producers of the King's Speech for bringing out the problem I share with so many other people. I suspect however this fascination will only last a few years and we will continue to go on as before. Meanwhile I have my blog.

When no doctor is better.

This story popped up recently. A similar story pops up a couple of times a year in Canada. Sometimes it is a radiologist, it could be a surgeon, even an anaesthesiologist. CT scans came into being while I was in medical school which is a really long time ago so if a radiologist hasn't been trained in reading what has become a pretty basic test, one has to wonder when did he train and the real question which the story doesn't answer is where did he train?

On the other hand except when a CT scan is done for trauma or a suspected intracranial bleed, interpretation is pretty much something that needs to done in days not in minutes. Urgent CTs are usually read by surgeons or ER docs anyway. Remember, a CT scan is a computer generated interpretation of multiple X-ray beams which means the image we seen on the screen or in the old days printed on a film, is really a series of 1 s and 0 s which means that it can nowadays easily be sent electronically in real time to be read by somebody who knows what he is doing. This is already being done and we of course hear of X-rays being outsourced to other countries.

Surgery and anaesthesiology of course can't yet be reduced to 1 s and 0 s which means that both of us have to be on site to do our jobs. This is causing problems in rural Canada and I suspect in the rural US.

Canada and the US are gradually becoming exclusively urbanized countries. In our province which is felt to the redneck heartland of Canada, 2/3 of the population actually live in the two largest cities. Rural populations are shrinking or not expanding; our neighbouring mostly rural province has the same population as it had in 1920. No one is denying the importance of the rural areas in producing our food, our lumber,drilling for oil and mining our minerals; clearly people need to live in there and clearly people want to live there. Increasing the rural population is devoted only to those activities with the rural population seeking services in the cites. Many people in fact involved in activities like mining and oil live temporarily in those communities while their families now live in the cities. Whereas people in rural areas used to buy their clothes at the local Saan, their hardware at the local hardware store and their groceries at the local grocery store, they now drive 1-2 hours to shop at Winners, Home Depot and Costco.

When I was in medical school, smaller hospitals still did a lot of surgery. The surgeons were usually individuals who had done a lot of surgery either in a formal residency training program or as medical missionaries. They did general practice as well and could do hernias, gall bladders, Caesarian sections and some orthopedics. A few of the these surgeons were Brits who had gotten sick of waiting for a consultant to die so they could have his position and they were very well trained. More recently we have South African surgeons fleeing their country for greener pastures who are largely good surgeons as well. (There was the embarrassment of the South African orthopedic surgeon practising in rural Saskatchewan who was wanted by the Truth and Reconciliation Commission to explain his actions while working with the army; something about death squads.)

Times are changing. Surgical training is increasing becoming pyramidal with senior residents doing a lot of surgery and junior residents doing almost none. The days when a doctor who was interested in doing a little surgery could sign up for one or two years and expect to get experience are over. I suspect the situation in other countries in the British Commonwealth where a lot of Canadians went to get surgical training is the same. At the same time job prospects for Brits are better with the government having created more consultancies. Further, graduates of Canadian training programs are reluctant to move to rural communities where they can be guaranteed to be on call all the time and may have to supplement their income by being family docs (something which under our licensing policies isn't even possible anymore).

Anaesthesia in rural areas is provided by what is a uniquely Canadian job, the GP-Anesthetist (GPA). These are family docs who have done an extra year of anaesthesia training. Our program trains these individuals, they are for the most part excellent well motivated docs. (Many of them in fact chose to do the entire residency). In the community these docs typically will do one or more morning lists with their offices in the afternoon. They also take call for anesthesia in their hospitals.

Back in the 1990s when jobs for specialists were lacking we noticed that quite a few suburban hospitals around our city were being staffed by these GPA s, some in fact were working full-time in anaesthesia. Many of us felt that these ORs should be staffed by specialists and the result was that another of the hospitals in our city refused to train GPA s. This precipitated the usual shzt storm and we were able to reinstate the program with the stipulation that the trainees had to be sponsored by a community suitably distant from our city with a "commitment" to work there. These commitments and $1.65 will get you a coffee and there still are a number of GPA s encroaching on our city (largely because specialists don't want to work and take call in those suburban hospitals).

When working with a GPA trainee I try to emphasize what should be the key point in their training. Not what they can do but rather what they can't do and more importantly what they can do but shouldn't do. For example a certain surgical procedure may be well within the skill set of both a surgeon and an anaesthesiologist but the hospital may not be able to care for the patient post-operatively. Worse the anaesthetist may be able to give a good anaesthetic but the surgeon may not be able to do the surgery competently or worst still the surgeon can do the surgery but the anaesthesiologist cannot do the patient. An interesting case took place many years ago in a rural hospital with an itinerant surgeon from the city. The surgeon wanted to do a hernia repair in a neonate. The GPA quite correctly said that he could not do the case. The surgeon who is a bit of a bully offered him a compromise. "I will start the IV and intubate the patient for you," said the gracious surgeon. You know where this is going. The surgeon could start the IV but couldn't intubate or bag the patient. There was a lot of fuss and apparently the child did okay and had an uneventful surgery weeks later in the city hospital to which he should have been referred in the first place.

The justification for keeping operating rooms open in these small centres is often so that locals can get their surgery close to home. Frequently now much of their surgical volume comes from itinerant surgeons from the city who are looking for OR time and compliant anaesthesiologists who won't trouble them with concerns about the patient's medical problems, ICU beds or regional blocks. The patients are as likely to have come from the city as they are to be locals. Full-time surgeons have as I mentioned above largely fled these smaller hospitals. A few specialists have actually been allowed by smaller hospitals to develop boutique practices where they practice their specialty in the hospital but do not do trauma or take call.

The problem is as has become very clear is that as surgical volume drops complications go up. In fact the administrator of our hospital at a meeting was quite clear about this when she said at a meeting I was at that if you have surgery at a hospital with fewer than 50 beds, you are putting yourself in harm's way. She said this in a closed meeting. No public official would ever say that in public.

People in small towns while happy to drive to the city to do their shopping are attached to their little hospitals. Reducing any service, let alone close them is political suicide. In many small communities the hospital is the town's largest employer. Closing these hospitals is not the answer, they need their emergency rooms, they need to be able to stabilize patients for transport,they need to be able to take patients for short admission and be able to act as convalescent care areas where people can recover from surgery or serious medical problems close to home. It is hard to think of an surgical problem that is not amenable to stabilization and transfer to a more advanced surgery centre.

Obstetrics is of course the justification for most small hospitals keeping their surgery units. This would be a good justification except that currently many of them are transferring in their patients to deliver in the city as family docs flee obstetrics or refuse to be on call 24/7 meaning that our hospital gets a significant number of transfers because nobody in town is doing obstetrics that (usually) weekend. Further it is getting harder to find someone trained in general surgery who is capable of doing a caesarian section. The days of surgery (or obstetrics) residents doing off-service rotations are over.

But getting back to the problem of the less than competent radiologist; we also have the problem of the less than competent surgeon who is hired to staff a rural hospital. I have actually spent whole evenings on call where every case we did was a complication of surgery done at rural hospitals by surgeons with questionable training.

We also have the problem of the less than competent anaesthesiologist. A few years ago we had an apparently specialty trained anaesthesiologist from another country who married a Canadian teacher who lived in our city. She asked to do a self-funded (meaning unpaid) residency which our chairman approved. I soon noticed she was showing up in my room to work with me quite a bit. She was very pleasant to talk with but in my mind was functioning at a very junior resident level and had some very bad habits. After a while she asked me if I would do a letter of reference for her. I assumed that she was applying for a Canadian residency which we had discussed. It was with some shock that about a month later I received a letter from a hospital an hour away asking for a letter of reference for a staff position. As I said, I like her but I felt I could not recommend her; I talked with the residency program director, who disavowed any responsibility for her saying it was the chairman who had arranged her "residency". I therefore wrote a letter stating that I felt that she was not capable of independent practice to Canadian community standards. She still got the job.

The point of all of this is that sometimes it is better not to have a doctor at all and deal with that problem than to have a doctor who is incompetent. This is not limited to specialists, an incompetent family doctor can hurt rather than help a community. The resources needed to keep these small operating rooms operating could be more efficiently used opening more rooms in larger centres. Residents of rural areas want access to health care which is understandable; what they fail to realize is that by keeping access to less than competent care they are preventing themselves and unfortunately others from accessing competent care.

Into the Maw of the Insurance Industry

I have been fortunate not to have been involved in any motor vehicle accidents of significance. I have had lots of car stereos stolen back when car stereos were stolen but have for the past 10 or so years, just paid my premiums.

Unfortunately this summer while at work and fortunately not doing anything, I got a call from my wife who had been T-boned at a stop light. I dropped everything and raced over there forgetting of course my wallet which had the automobile association card to find our beloved Volvo station wagon severely dented on the driver's side, airbags deployed. A few feet away was the Porsche Cayenne which had T-boned her.

The first thing the driver of the Porsche had said to my wife was," You ran the red light." (not something , like are you okay?) He was quickly corrected by the lady who had been in the next lane to him who informed him that the light had still been red in his direction when he decided to accelerate into the side of our car. On my arrival to the accident scene, I knocked on his window and asked for his insurance info and he told me to go away. All in all not a pleasant encounter.

But nobody was hurt, it was not our fault and we have insurance. Everything should be okay?

We got the address of a body shop recommended by the Volvo dealer and had the car towed there. I drove back to work, my wife got a ride home with the police (after they charged the other driver).

I am less patient and perhaps have unrealistic ideas of how long it should take to fix things but as a month passed I began to wonder why our car wasn't ready. Don't worry said my wife, these things take time. Six weeks passed and our car wasn't ready. We had rented a Kia Rio to get around town plus we had our third car so we weren't greatly inconvenienced? September came and we went off on a vacation to Europe fully expecting to have our car back when we returned. It was now getting close to 3 months.

A couple of days into our European vacation, we came back to our hotel to find a text message from our son. Our other Volvo (S-40) which was parked on the street due to work on our sidewalks which had made our driveway inaccessible had been spray painted and the window had been smashed along with every other car on our street. We sighed, told him to secure it as best he could, remove all the valuables and we would take care of it when we got back. No worry, we have insurance.

Arriving back a week or so later, my wife drove our spray painted car to the body shop where our other car was hopefully fixed and ready to come home. It was then that the body shop told us that it would be two weeks before our first car would be ready and that the reason for this was that the insurance company was questioning every single repair. Because Volvo parts are expensive and have to come from Sweden, body shops don't like ordering them if they aren't going to get paid for them. That meant that after the insurance company approved the repair, there was a one week wait for the part and this happened more than once. The adjudicator on our case was apparently a notorious hardass hated throughout the body shop community.

I decided that it was time to have a little talk with our insurance company. This required multiple minutes on hold, redials after being disconnected, explaining my case over and over again etc. Finally I left a message with our adjuster, saying if I didn't get a reply within an hour, I would be changing insurance companies. 55 minutes later I got a call back, "You seem to be upset about something", she said. Meanwhile I learned that our second car was being adjudicated by the some adjudicator. I asked the company if they minded assigning someone else which they eventually did.

We still had one car in the body shop. This car only had some spray paint on it, smashed windows and a dent in the door. After about two weeks I phoned the body shop to ask why it wasn't ready. "We are still waiting for the insurance company to approve the repairs", was the answer. Adjudicator #2 on his initial assessment missed a whole bunch of stuff that also had to be fixed. Back on the phone to our adjuster whose phone number I had now memorized. "I don't know what you are so upset about, " she said, "90% of the time we miss something the first time we check out a car."

We now have both cars back. I looked at changing insurance companies but decided that it was too much of a hassle plus as our insurance is a group rate through the medical association, we would probably pay more although, I wonder whether paying more might have been worth it.

Eventually we got back both our cars.

As an aside the kids who vandalized our car got caught. It turned out they were 15 year olds from the adjacent (richer than our) neighbourhood. About a month after the vandalization, I got a knock on my door one Saturday evening. There was a plain clothes policeman on our porch. "I have a letter of apology from one of the kids," he said, and produced a type-written unsigned letter. I read it briefly. We apologize a lot in Canada so I have heard or read a lot of apologies and this one covered all the bases. I asked my friendly policeman if the apology came with the $500 deductable I was going to have to pay, and if maybe I could also get an apology from the parents who didn't know what their kids were doing a 3 in the morning and also how could kids vandalize 100 cars without the police being aware of it? He didn't really have a good answer for any of that. I didn't ask him, but wondered whether if it had been a 15 year old from a worse neighbourhood, a plainclothes officer would have hand-delivered an apology?

Downregulation of Stat

The most overused word in medicine has to be "stat". This is supposed to mean "right away because harm will come to the patient if something isn't done" but has come to mean "I do don't really know if this has to be done right away but it would be much more convenient for me if it was done right away" or "I don't really think this has to done right away but I know if I want to get the results in a timely fashion, I have to order it stat".

I have been thinking a lot about this lately because of problems I have been having with my friends over in the respiratory technology division. Lately arterial blood gas machines have evolved so that they now give results such as hemoglobins, electrolytes, calciums and blood glucose in addition to pHs etc. This has been extremely helpful for those of us in anaesthesiology and ICU who occasionally actually need the results. For example when a patient is bleeding, a 30 minute old hemoglobin is of little use. Likewise your TURP who looks funny in the recovery room after his 2 hour TURP, you would feel a lot better starting your next case or going home knowing what his sodium is, not to mention getting the phone call from the lab 45 minutes after your patient with the double figure sodium had his seizure is pretty useless. The problem is of course when you order a stat Hb because your patient is bleeding, it gets queued behind all the other stat Hbs which were ordered for other reasons (baseline, patient seemed off etc). Don't get me started on trying to get a stat PT, PTT. Phoning the lab to explain that your test really is STAT is a useless exercise.

Unfortunately our friends in the ER have cottoned on to this. Lab work in the ER is as I remember a huge hassle when you are trying to juggle multiple patients and the lab values are important in your decision tree (and to going home when your shift is over). Consequently my friends in the ER also started using the blood gas machine to get what they considered to be stat blood work. Rather than do an arterial stick however they (as do we) were sending these as venous blood gases.

This has predictably caused more work for the respiratory techs who have to run these blood gases. Blood gas machines aren't that difficult to use. In my residency we ran our own gases as did the ICU nurses. Part of this is a turf issue with the RTs not wishing to lose control of the blood gas machine but at the same time not really wanting to work to hard. Our respiratory departments solution to this workload however was to unilaterally announce that they would no longer run venous blood gases from the OR (not however from the ER). This is not a problem during the day when our techs can do the gases but in the evenings and on weekends we cannot get our "stat" blood work. This has lead to me having to make a number of increasingly pointed phone calls, letters and emails to various people.

I am not a big fan of blood work anyway as I have blogged. Even when I have an art line, I do ABGs infrequently. I have a pulse oximeter and except when it is really important to control the CO2, I use the ET CO2. Hemoglobins are different matter. With routine "preventative" transfusions being quite correctly out of fashion we now allow our patients to flirt with hemoglobins of 7 or 8. This is a delicate balance requiring frequent and most importantly timely hemoglobins. When I know the patient is going to bleed, I usually have an art line. I of course cannot anticipate when the bowel resection or joint revision is going to go south and for those I usually draw blood from whatever vein is available so I can see where I am. The other day when one of our backs started bleeding profusely, mindful of the ongoing problem with venous blood gases I drew some blood and sent it stat to the lab. After 30 or so minutes we phoned the lab for the results and were told it would be another 20 minutes (and another 30 minutes for the stat PT, PTT we had sent at the same time). I think next time I am just going to fight with RT.

Of course stat is egregiously misused in the surgical setting especially by our obstetrical colleagues. Every non booked C/S is of course stat. These range from prolapsed cords to patient wishing to have her baby today for astrological reasons (we have done at least one such stat C/S). Attempts to ask the person who phones you just how urgent this case is (i.e. do I need to call in the second call) usually gets a rude response.

The OR has of course been burned by this in the past and classifies cases by urgency. Our hospital uses E1,E2, E6 and E24, the number refers to within how many hours the case should be done. This system is susceptible to gaming as well. I find it amazing that appendectomies are only E1 or E2 after 1600 on weekdays and on weekends of course. I have of course never figured out whether an E24 becomes an E1 after 23 hours. The surgeon would say so, unless of course he is already operating or has a office ( or is baby sitting).

Where I used to work all the surgeons also booked their booked cases as urgent rather than elective. As a surgeon explained to me, if he booked his cases elective they would be continuously bumped by his and everybody else's urgent cases. The cardiac surgeons where I trained booked all their CABGs as urgent, which also helped to inflate their wait list number so that they could point out that the wait time for an "elective" CABG was 9 months. Problem was that they never did any elective CABGs, they were all emergencies (and usually done within 2 months of symptoms onset).

Part of the whole system is our unwillingness to triage patients; to say what truely has to be done right away, what can wait a little while and what can be done whenever (or never). Individually we may be willing to do this but we don't trust our colleagues to do the same and as we all use (and pee in?) the same pool of resources we try to get the best for ourselves and our patients.

I am however getting tired of all of this and am awaiting a resolution. STAT of course.

Another reason why Healthcare Costs are Soaring

Our department is trialling new machines this month. Our old machines are still functional but according to the manufacturer will not be serviceable in three years time.

Just before Christmas, I learned that we would be getting 8 new machines. As department head I was a little confused because no one had approached me about these machines. Worse I was told that we would have no choice about what machine it was and that we would not be able to trial the machine. The reason I was given was that money was now available for the purchase of these machines and it had to be spent now or it would be lost forever.

Worse still was that the machines that had been chosen for us were the Draeger Primus machine. Our department bought two of these a couple of years ago for use in Obstetrics. Unfortunately as I blogged about, these machines if unplugged have a 30 minute boot up which of course makes them unsuitable for obstetrics (or for anaesthesia in general for that matter). In addition they have a tiny work surface, do not have the modes of ventilation some of us have come to love and of course they have Draeger's annoying wolf-crying alarms.

About a year ago my predecessor was faced with a similar demand. Get new monitors or the money disappears. He replaced our perfectly good monitors with new monitors from Philips which have been disastrous.

I wasn't too happy about being rail-roaded into buying machines that I certainly didn't want and the rest of my department didn't want so after a few few phone calls my reasoning was thus: when if three years we actually do need new machines, what are they going to do? shut down the OR?. Of course not, the money will come from somewhere. I also got the strong impression that we were being railroaded into taking machines that somebody else had already rejected.

So I phoned up the lady who is in charge of purchasing these machines. She is as it happens a nurse who was in charge of the neurosurgical ORs at the Centre of Excellence when I worked there. I told her that we did not want the machines, that we realized that we were going to "lose" the money; that we did not care and that we would let the chips fall where they may. She just said, "I hope you know what what you're doing BH". I said I did.

One hour later I got a phone call from the same person, asking if I would be willing to trial a different machine.

BH 1 Administration 0.

Seriously though, in twenty years I have seen so much perfectly good equipment thrown out because the capital budget had to used up. Some new equipment has been an improvement over what we had before, quite a lot of new equipment has been a huge step backwards.

As an aside, it now difficult to find a machine that is not completely electronic, which of course makes them susceptible to software and hardware problems and of course a software glitch could easily disable an entire department's computers. This usually requires a tech from the company to come in from out of town. I long for the old mechanical machines with their simplicity and easy serviceability. I challenge anybody to prove that our newer machines are anymore safe than the old mechanical machines people of my vintage trained on.